A Pint of Sweat Will Save a Gallon of Blood
A Call for Randomized Trials of Anticoagulation in End-Stage Renal Disease
Approximately 430 000 patients were receiving maintenance dialysis in the United States in 2011.1 Compared with the general population, atrial fibrillation is far more common2 and associated with a much higher risk of stroke in the dialysis population.3 Thus, there is an important need to define and apply strategies to reduce stroke in patients receiving dialysis with atrial fibrillation.
Article see p 1196
Warfarin for atrial fibrillation is one of the most successful treatments in all of medicine, preventing nearly two thirds of strokes in the general atrial fibrillation population.4 Approximately one fifth of all strokes are related to atrial fibrillation, and these strokes are more frequently disabling or fatal than strokes associated with other conditions. It is now well established that impaired kidney function is associated with increased risks of stroke and of bleeding associated with the use of anticoagulation.5 Patients with mild to moderate chronic kidney disease (CKD) and atrial fibrillation experience greater relative and absolute benefits from warfarin therapy.6 Despite the lack of evidence derived from randomized clinical trials in the dialysis population, clinical practice guidelines from Kidney Disease: Improving Global Outcomes (KDIGO) published in 20067 recommended that warfarin be used as per American Heart Association guidelines for atrial fibrillation with the caveat that “dialysis patients are at increased risk for bleeding and careful monitoring should accompany intervention.”
Since then, several observational studies have questioned the …